Authorization to Use or Disclose Protected Health Information 2018-03-06T17:01:03+00:00

Please submit a form for each of the following:

  • Parent, legal guardian, or significant other
  • Emergency Contact
  • Primary Doctor
  • Other

If you would like to opt out and not give authorization to disclose, please fill out your information first and then write DECLINE in the second portion of the form. This form will need to be signed for your file.

After submission, please wait to be redirected to our signature page. After the signing the form, please press return to the original page to fill out all four forms needed.

 

Remember, after submission, please wait to be redirected to our signature page. After the signing the form, please press return to the original page to fill out all four forms needed.